Case 1
55 y male patient, smoker, HTN and has pace maker. He works as hospital manager. Presented with CLTI in the form of non healed ulcer on the 2nd to rest pain. He had conflicting advices by multiple surgeons. one is to have enodvascular treatment with SFA stent and second to have fem-pop bypass. He came to your clinic seeking your advice.
Q1 How would you assess this in clinic?
Q2 Is there any further investigation to help you to decide your most suitable treatment strategy?
Q3 How would you consent this patient for open bypass surgery?
Q4 Please write your operative steps for fem-pop bypass in the same way would write it in your operation notes?
Please avoid using AI tool to answer your questions. Please support your answers with guidelines recommendations or research evidence.

1 . I would asses this by Hx ( HTN,DM,SMOKING,hyperlipidemia, previous open or endo vascular surgery , cardiac symptoms) , intermitent claudication , claudication distance
I would ask about neurogenic claudication
Examination: palpaiton of both femoral pulses
HHD fro distal vessels
ABPI measurment
Ulcer examantion and care
_____________
2. I would order full lab (CBC/INR,KFT,LFT), Duplex vein mapping on both GSV to dtermine if the payient van undergo autogenous bypass
3. I would tell the patient the possible complication which is above knee amputation and may be death on thr table , hematoma on any wound , infection
4. Incsion femoral , control of femoral proximal and distal
Poplitral inciscion control of popliteal proximal and distla
Harvesting of the GSV , proxinal anasmosis and tunnling of the veib then distal anasmosis
2 redivacs are put on each wound and 1ry closure
Q1 How would you assess this in clinic?
patient general condition
young working patient , ambulating with long life expectancy , with salvageable limb
patient is candidate for revascularization
limb staging according to wifi classification stage 1
anatomical pattern
long segment of SFA , with patent proximal third of sfa away from bifurcation
no previous intervention
good distal run off of pop artery supra genicular
Q2 Is there any further investigation to help you to decide your most suitable treatment strategy?
cardiac assessment , echocardiography
saphenous mapping
Q3 How would you consent this patient for open bypass surgery?
i will discuss with the indication for the surgery
patency of open surgery benefit more than the endovascular
Q4 Please write your operative steps for fem-pop bypass in the same way would write it in your operation notes?
on supine position , after general or spinal anesthesia
marking of the great saphenous vein using the duplex
sterilization of the whole right lower limb and the left limb till the knee
long c shape skin incision of the groin
opening the camper and scarpa fascia , identification of the lymp node and moving it medially
exploration and identification of the CFA , SFA and PF using sharp dissection
at the distal third of thigh medial long skin and subcutaneous incision , opening the muscle fascia ,
identification of the sartorius muscle and moving it inferiorly
sharp dissection on the pop artery supra genicular at the end of hunter canal
separation from the pop vein
tunneling through anatomical course of the hunter canal
after 3 minutes of heparinization , clamping of the cfa and sfa and pf
long arteriotomy of cfa , end to side anastomosis the reversed gsv to the cfa
gsv passing through the tunnel then end to side anastomis to the pop artery
good hemostasis , drains insertion
closure of skin layer by layer and clean dressing application
A(1):
(1) Assessment of patient by:
-PMHx htn and IHD
asking about medications taken.
Special habits like smoking
-Assessing fitness for intervention by fraility and METS scores.
-Clinical examination: inspection of the non healed ulcer, assessing pulsations, coldness of skin, sensory and motor power of RT foot, capillary refill time.
-ABPI to detect degree of ischemia.
-Using WIFI classification to detect level of ulcer.
A(2) -Labs:
ESR and CRP to rule out vasculitis
HgbA1C to rule of D.M
Lipid profile
-Plain X-ray RT foot to rule out osteomyelitis
-ECHO
-Saphenous mapping of both L.L for GSV conduit
-GLASS classification
A(3) I will explain to the patient the nature of disease for intervention to restore vascularity and possibiltiy of complications as bleeding, pseudoaneuryms, infected wound post-operative and possibility of graft thrombosis.
Possibility of major amputation and the need of follow up over a period of 5 years after intervention.
A(4) Steps:
-Under spinal anesthenia and maybe added epidural
-Drapping then sterilization of the patient infra-umbilical till feet of both L.L
-RT Common femoral A. cutdown at mid-inguinal point to exposure RT CFA, SFA and -Profunda femoris A.
-RT supra-inguinal popliteal A. is exposed
-Harvesting the RT GSV and ligation of its tributaries then flushing the vein with heparinized saline.
-Proximal claming the RT CFA, RT Profunda femoris A. and RT SFA the arteriotomy of RT CFA is done and full heparinization.
-Proximal anastomosis is done usinf reversed GSV and then tunneller is used to create a tunnel subsartorial and the GSV is passed to reach supra genicular portion .
-Declamping and then another clamp applied post proximal anastomosis over the vein graft and another one over the popliteal A.
-Distal arteriotomy is done and distal anastomosis is done.
-declamping and assessmet of pulse distal to anastomosis and using duplex-US to assess the folow over the crural vessels.
-Good hemostasis and application of redivacs.
-Wound closure.
Q1:
Full assessment as usual is a must
>> History :
Full medical history including risk factors as smoking and its index, the duration, and severity of the symptoms, asking also about previous cardiovascular events
also I will ask about previous attempts of conservative management
>> Examination:
Full vascular and general examination including neurogenic examination to exclude neurogenic cause of the pain and ulcer
local examination of the ulcer and surrounding soft tissue
Q2:
as CTA is accompanied with the question it is already orderd i will need
Duplex :
to evaluate the suitability of GSV to be used as a conduit in bypass
in addition to Cardiac evaluation as Echo and stress test to assess patient fitness
Guideline :
European Society for Vascular Surgery (ESVS) 2023 guidelines recommend comprehensive anatomical and physiological assessment before revascularization to optimize outcomes.
Q3:
I will obtain informed consent which includes the nature of the disease and the nature of the surgery with its expected benefit and possible complications
Q4:
Operative Steps:
> Exposure:
longitudinal groin incision to expose the common femoral artery.
Distal incision to expose the popliteal artery ( depends on which segment i can do the bypass) .
> dissection and control of the common femoral and popliteal arteries using clamps (after heparinzation)
> GSV harvesting through skip incisions .
Anastomosis:
Proximal end of the graft anastomosed to the common femoral artery in an end-to-side fashion
Distal end anastomosed to the popliteal artery in an end-to-side manner.
Clamp release and flow assessment with intraoperative Doppler or direct angiography .
Closure:
Wound closure in layers with absorbable sutures for subcutaneous tissue and interrupted skin sutures.
A1:
History taking social family medication anticoag regarding the pace maker allergy previous interventions
Gen exam ASA for fitness for surgery
Vascular exam with analysis of complaints pulsations and Doppler bilat ulcer and wound exam
Neurological exam to exclude neuropathic ulcer
Investigations
Labs full labs blood grouping cross matching
Xray foot for OM
ECG
A2:
Venous mapping both LL for GSV conduit
A3:
Consent of the surgery steps and vein harvesting wounds post op care medications and follow up plans smoking and risk factors modification HTN control smoking cessation exercise anesthesia by anesthesiologist
Consent for surgical debridement of the ulcer and dressing with offloading
A4:
Marking the vein and the limb
Anesthesia spinal epidural for post op pain or general according to anesthesiologist
Drapping and sterilization of both limbs after positioning supine
Longitudinal incision with good isolation of the ulcer
Exposure and control of CFA PFA SFA
Longitudinal incision supragenicular pop P1 and control
Vein harvesting and flushing and dilatation with hep saline ligation of trebutaries in reversed graft or valvutome in insitu graft
Tunneler to make a subsartorial or sbfacial bypass in reversed graft
systemic iv heparinization
Inform the anesthesiologist before clamping and declamping steps
Longitudinal arteriotomy extend to bifurcation
Endarterectomy if needed
Proximal anstmosis prolene 5/0 or 6/0
Declamping of the inflow with hemostasis and clamping just distal to anastmosis to restore the flow through PFA
Withdraw the conduit through the tunnel
Adjust the length of the graft to the site of distal anastomosis after longitudinal ATK pop arteriotomy with clamping proximallly and distally
Endarterectomy if needed
Anastmosis with prolene 6/0
Declamping of the proximal graft clamp then the outflow clamp
Good hemostasis
Intra op doppler distal to the anastomosis or feel the distal pulse
Suction drains
Closure in layers
Vac dressing if available
Q(1):
(1) Assessment of patient by:
-History taking: smoking ( amount per day), HTN, Pacemaker (IHD)
asking about medications taken.
-Assessing fitness for intervention by fraility and METS scores.
-Clinical examination: inspection of the non healed ulcer, assessing pulsations, coldness of skin, sensory and motor power of RT foot, capillary refill time.
-ABPI to detect degree of ischemia.
-Using WIFI classification to detect level of ulcer.
(2) -Labs:
ESR and CRP to rule out vasculitis
HgbA1C to rule of D.M
Lipid profile
-Plain X-ray RT foot to rule out osteomyelitis
-ECHO
-Saphenous mapping of both L.L for GSV conduit
-GLASS classification
(3) I will explain to the patiebt the nature of disease and urgeny for intervention to restore vascularity and possibiltiy of complications as bleeding, pseudoaneuryms, infected wound post-operative and possibility of graft thrombosis.
Possibility of major amputation and the need of follow up over a period of 5 years after intervention.
Q(4) Steps:
-Under spinal anesthenia and maybe added epidural
-Drapping then sterilization of the patient infra-umbilical till feet of both L.L
-RT Common femoral A. cutdown at mid-inguinal point to exposure RT CFA, SFA and -Profunda femoris A.
-RT supra-inguinal popliteal A. is exposed
-Harvesting the RT GSV and ligation of its tributaries then flushing the vein with heparinized saline.
-Proximal claming the RT CFA, RT Profunda femoris A. and RT SFA the arteriotomy of RT CFA is done and full heparinization.
-Proximal anastomosis is done usinf reversed GSV and then tunneller is used to create a tunnel subsartorial and the GSV is passed to reach supra genicular portion .
-Declamping and then another clamp applied post proximal anastomosis over the vein graft and another one over the popliteal A.
-Distal arteriotomy is done and distal anastomosis is done.
-declamping and assessmet of pulse distal to anastomosis and using duplex-US to assess the folow over the crural vessels.
-Good hemostasis and application of redivacs.
-Wound closure.
In guide lines:
In average risk CLTI patients with infrainguinal disease, base decision of endovascular vs. open surgical intervention on severity of limb threat (WIFI) anf anatomic disease pattern (GLASS) and availability of autologous vein.
Grade 1C Almasri,2018.
Q1 assess the pt through
1- general condition of pt , fittness score , cardio vascular risks , pt candidacy for surgical interference
2- wifi staging of ulcer
W 1 f 1
3- level of arterial impairment
Q2 ct angiography
Q3 concent the pt through following :
1- why operation
2-risk of operation
3- steps of operation and anasthesia
4- out comes morbidites and moralities
Periprocedural
5-duration of hospital stay
6- post op medication and physiotherapy
7 – long duration of follow up
Q 4
Concent
Anasthesia
Sterilization
Inflow exposure
Outflow exposure
Vein harvest
Systemic heparinization
Angiography at outflow
Inflow endarterectomy if needed
Tunneling of graft
Inflow anastomosis
Out flow anastomosis
Flush before last stitch
Angiography or doppler
Closure of sc tissue
Drain
Negative pressure dressing
Q1:
full history of the patient and his cardiac status and other co morbidities
full examination of the pulse abdomen and both upper limbs and both femoral and lower limb pulsation
examination of the ulcer
Q2:
full blood count and kidney function tests and ECG and coagulation profile and lipid profile and blood cross matching
duplex assessment venous mapping of both lower limb GSV to assess availability of venous conduit
Q3:
anesthesia risk if general or general and epidural
consented for risk of bleeding and blood transfusion
risk of wound infection risk of thrombosis of the graft
consented for use of the contrast at the end of the procedure for completion angiography
Q4:
under general and epidural anesthesia
the patient was positioned supine with thigh externally rotated and the knee partially flexed
the skin was prepped and draped from the umbilicus to both lower limbs and the perineum was covered
two teams one for exposure of the CFA as inflow artery and another one for exposure of the POP artery P1 segment supragenicular
CFA: longitudinal incision at a point midway between anterior superior iliac spine and symphysis pubis and more medially from the same incision start harvesting of the GSV
exposure of CFA and PFA and SFA
exposure of the POP a using incision anterior border of the sartorius muscle control of the popliteal artery
harvesting of the GSV and ligation of side branches
preparation of the GSV dilatation using heparinized saline and control of any missed side branches
tunneling of the revised GSV sub sartorial using tunneler instrument
asking the anesthetist to give 5000 iu heparin before cross clamping
control of popliteal artery proximal and distal and anastmosis of the graft
extension of the knee and measuring the adequate length of the graft with removal of the remaining
proximal anastemosis was done
doppler assessment of the graft and completion angiography
good homeostasis
closure of the harvest incisions and groin and popliteal incision with drains out in posterior wound
A1 assess patient history risk factors for smoking -HTN -DM – hyperlipidemia
assess patient complain and exclude other causes
assess cardiac condition and function state of the patient like MET score
drug history and allergies
examination
inspect ll and foot ulcer
palpate patient pulses bilateral -crt – motor power
measure ABI
A2 labs CBC -kidney function test – coagulation profile – HBA1C -lipid profile
Esr and CRP to exclude vasculitis
ecg – echo dot cardiac assessment
bil saphenous mapping and artieral duplex
x-ray foot to exclude osteomyelitis
A3 consent patient about operation and site of incision and conduit options (natural Vs synthetic
patency rate
other alternative like angio or medical treatment only
type of anathesthia
possible complication like infection -thrombosis -pseudoaneurysm – bleeding
surveillance postoperative
importance of stick to post op medication and control of risk factors
A4 steps
anathesthia (spinal epidural )
supine position
steralization of full LL limb and lower abdomen
exposure of CFA- SFA-profunda through longitudinal incision
extent the incision medially to expose GSV
dissect over GSV through skip incision
expose supragenicular pop artery
through the same incision we get the GSV to avoid undermining
harvest GSV and make sure all it’s tributaries are ligated and it flushes well using syringe fulled with heparinised syringe
tunnelling better subsartorial (although there is no difference in literature according to this metanalysis study
“”Effect of infrainguinal bypass tunneling technique on patency and amputation in patients with limb ischemia
Nallely Saldana-Ruiz et al. J Vasc Surg. 2021 Oct.”””
systemic heparnization
proximal clamping and arteriotomy of CFA and anastomosis with reversed GSV
declamping of CFA
passage of GSV in its tunnel
distal clamping and arteriotomy and make distal anastomsis
flushing before declamping
assess pulsation over the GSV and after distal anastomosis
we may do completion angio to make sure there is no distal lesion or usage of HHD
hemostasis
radivac insertion
wound closure
Q1 / Full history including symptom duration, ulcer details, and risk factors (smoking, HTN, pacemaker).
Examination: Pulses from femoral to foot, ulcer inspection
Measure ABI or toe pressures if available.
Q2 / Use duplex ultrasound if clarification needed and to assess GSV statue
Q3 / Explain femoral-popliteal bypass using reversed vein or prosthetic graft.
Benefits: Ulcer healing, pain relief, limb preservation.
Risks: Bleeding, infection, graft failure, nerve injury, limb loss, cardiac complications.
Alternatives: Endovascular treatment or conservative management.
Importance of smoking cessation and follow-up emphasized.
Q4 / Supine position, antiseptic prep, groin and popliteal incisions.
Expose femoral and popliteal arteries.
Harvest and reverse saphenous vein.
Proximal end-to-side anastomosis at femoral artery.
Subcutaneous tunnel creation.
Distal end-to-side anastomosis at popliteal artery.
Release clamps, check flow, achieve hemostasis.
wound closure.
Post-op monitoring, wound care, and follow-up.
Hi Ahmed,
Thanks for your good answers. Could you please expand on the post op instructions?
Why would you prefer the subcutaneous tunnel and what its limitation?
1 Full history especially co-morbidities ,risk factors for PAD and ulcer duration
Full examination especially ulcer charactrestics , pulse level
ABI
2 Surgical fitness and full lab
venous mapping for GSV
Assess distal runoff in CT angiography
3 open bypass surgery carries more risk but it’s more durable
Graft surveillance for 2 years at least
Medical ttt and risk factors modification
4 supine position
Spinal anasethia
CFA exposure at groin by longitudinal incision
Supra genicular pop A exposure
GSV graft harvesting
Tunneling of the graft subsartorial
Proximal anastmosis
Distal anastmosis
Check for distal pulsation or completion angiography
Closure of the wound in layers & suction drain
Hi Mosta good answers,
Could you please check if there is any study that compare the sub-sartorial to subcutaneous tunnelling?
is your graft reversed or non revered? Is this point is important to be mentioned on the Op notes?
Saldana-Ruiz N, Dominguez J, Ham SW, Rowe VL, Magee GA, Weaver FA, Han SM, Ziegler KR. Effect of infrainguinal bypass tunneling technique on patency and amputation in patients with limb ischemia. J Vasc Surg. 2021 Oct;74(4):1242-1250. doi: 10.1016/j.jvs.2021.03.023. Epub 2021 Apr 15. PMID: 33845170.
It’s reversed grqft and of course it’s important to mention that.
A1….
in my clinic, for a patient complaining of non-healing ulcer and rest pain, I will start by history-taking
analysis of ulcer: for how long, it presents
analysis of rest pain: onset, course, and duration
history of risk factors such as smoking, dyslipidemia, DM, and HTN
Cardiac history and medication history
then I will proceed with the examination
examination of distal pulsation
ABPI measurement
then I will ask for CRP, CBC, LFT, KFT, ECG,
finally, I will ask for imaging as arterial duplex US, CTA, and X-RAY of the foot
A2…
for this SFA occlusion in CTA, the patient has two available options for revascularization
either bypass or PTA
being young age I will ask for saphenous mapping duplex US if the patient has a single long segment of GSV I will go with fem-pop short bypass and this is supported by BEST-CLI trial
A3…
I will consent him for saphenous bypass surgery
type of anesthesia, possible complications such as graft occlusion, wound infection, secondary hemorrhage, amputation, and mortality risk
A4…
Hi, very good answer, But why would you ask for imaging as arterial duplex US, CTA, and X-RAY of the foot.
why would you do the distal anastomosis 1st? What do you mean with tunnel under deep fascia? what is the explanation for the sequence of de-clamping
Imaging as a part of initial assessment
CTA tp prepare for intervention
XRay to role out any underlaying OM
I USUALLY start with the difficult and deep anastomosis at first to make it more easier
I mean to put the graft under deep fascia not just subcutaneous to give it more support and protection
This sequence of declamping is to direct any air bubbles and tiny minute thrombi away from distal circulation
A1 the patient is 55 years old and energetic as employed hospital manager, so he has life expectancy more than 10 years and need durable revascularisation if available. He is smoker and hypertensive, more over, ct scan showed a lot of calcification, so he had atherosclerosis occlusive disease. He needs to stop smoking and control hypertension. If he is complaining of rt lower limb so, Endovascular option is best option but unfortunately he had long SFA segment occlusion with very small nipple and mild tortousity of rt common iliac artery. Therefore, ipsilateral or contralateral antegrade approaches are not too much favorable. We will assess for femoropopliteal bypass option as first mode of revascularisation if there is available autologus conduit and there is no infrapoplital disease.
A2 I will ask for venous duplex for both great saphenous veins.
The axial CT scan cuts to assess distal arteries
A3 I will consent him for follow up 5 years, stenosis of the graft and thrombosis, wound infection, graft infection, redo surgery, upto below knee amputation
A4 procedure: rt femropopliteal bypass
Position: supine with rt knee flexion
Anaesthia: epidural
Findings: after draping under complete aseptic technique, rt femoral exposure with bear in mind anteromedial calcification of rt common femoral artery, upper popliteal exposure. Great saphenous vein harvesting and assess its length comparable with the length of bypass . Then will do the anastmosis after loading dose of heparin. Assess the anastmosis intraoperative by duplex . Then good hemostasis and closure in layers
Very good answer for Q1,
Could you expand on the statement of 5 years of follow up? what is your evidence.
Would you consider to do endarterctomy of the femoral artery? how would you tunnel you graft? do you revers or non-revers?
Thx for your comment
According to this paper Golledge J, Moxon JV, Rowbotham S, Pinchbeck J, Yip L, Velu R, Quigley F, Jenkins J, Morris DR. Risk of major amputation in patients with intermittent claudication undergoing early revascularization. Br J Surg. 2018 May;105(6):699-708. doi: 10.1002/bjs.10765. Epub 2018 Mar 22. PMID: 29566427.
they followed up patients for amputation free survival for 5 years
ithink there is no need for endarterctomy because i have a healthy sufficient part of CFA for inflow
the tunnel will be subsartorial
iwill not reverese because there is no significant miss match as if i will do lower popliteal or tibial bypass beside there is no valvutome available
thx
The management plan is overall appropriate and addresses many key issues
several potential shortcomings need improvement can be highlighted
First
Delayed Initial Action: Chronic limb-threatening ischemia (CLTI) requires intervention within 2 weeks, but the patient had been symptomatic for 5 months.
Second
Rheumatology should be consulted at the time of diagnosis of CLTI, not after failed angioplasty, to co-manage the systemic vascular disease
Third
Exhaust all traditional revascularization options, including bypass, before performing LimbFlow
Fourth
An integrated wound care should be involved early to address the chronic ulcer alongside vascular intervention
Fifth
Toe Amputation Timing
The toe amputation was performed 2 months after LimbFlow Earlier surgical debridement or amputation should be considered when a toe is clearly non-viable to reduce infection risk
Andl lastly
Limited Consideration of Systemic Factors as steroid-induced diabetes, nutritional deficiencies from ileostomy, and the role of Crohn’s disease in healing was not adequately emphasized.
Thanks Ahmed, very good answer. I have updated the case. Could you have a go answering the new case. Thanks
Q1 How would you assess this in clinic?
Risk factors assessment+full lab assessment
Then
CTA assessment for anstomical assessment
Q2 Is there any further investigation to help you to decide your most suitable treatment strategy?
Duplex us for saphenous vein’s assessment
Q3 How would you consent this patient for open bypass surgery?
After patient education about benefits and drawbacks and expectations and risks+ follow up regemiens informed consent should be assigned By the patient
Q4 Please write your operative steps for fem-pop bypass in the same way would write it in your operation notes?
Anathesia+ab
Sterilisation+ fem incision+ preparation of veins conduit+ pop incision
Tunling
Proximal then distal anastomosis+ flow assessment+ Wound closure
.
Abdelraheem, Could you give more details on operative notes